History and Presenting Symptoms
The patient is a 52-year-old male, who was previously treated successfully for a lumbar disc problem, and who now returns to this clinic reporting pain and skin thickening (callus formation) on the bottoms of both feet. He has tried several remedies, but his calluses always return.
Exam Findings
Vitals. This middle-aged, physically active corporate executive weighs 175 lbs, which at 5’10’’ results in a BMI of 25 – he is on the borderline of overweight. Because of the results of a recent key executive physical exam, which showed an increased low density lipoprotein (high LDL), he has been working out regularly and is generally quite fit. Physical inspection indicates that some of his excess weight may be lean body mass. He is a non-smoker, and his blood pressure is within the normal range.
Posture and gait. Standing postural evaluation finds a slight lumbar list to the right, with compensatory balancing in the lower thoracic spine. He has a forward pelvis, and a decreased lumbar lordosis. He also demonstrates bilateral flat feet (pes planus), with no medial arches and bilateral calcaneal eversion. Both feet toe out during walking.
Chiropractic evaluation. The lumbar spine is moderately tender throughout, and he demonstrates a generalized loss of vertebral mobility. Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with some local tenderness. These segmental dysfunctions demonstrate loss of endrange mobility in all directions. Additional subluxations are noted at T9/T10 and C6/7. Orthopedic and neurological provocative testing of the spine and pelvis is negative.
Primary complaint. Lower extremity examination finds thickening of the skin and tenderness to palpation over the heads of the second and third metatarsal bones on both feet. This is in the anterior transverse arch region. All foot and ankle ranges of motion are full and pain-free, and manual muscle testing finds no evidence of weakness in the surrounding musculature. Squeeze test is negative for interdigital irritation.
Imaging
Upright, weight-bearing X-rays of the lumbar spine demonstrate moderate loss of intervertebral disc height at L4/L5 and L5/S1, with small osteophyte formation at those levels. A slight discrepancy in femur head heights is noted, with a difference of 3mm (right side lower). A moderate lumbar curvature (4°) is noted, convex to the right side, and both the sacral base and the iliac crest are lower on the right. The sacral base angle and measured lumbar lordosis are within normal limits.
Clinical Impression
Repetitive biomechanical stress to the tissues underneath the 2nd and 3rd metatarsal heads, resulting in callus formation. This is accompanied by chronic lumbopelvic spinal subluxations secondary to long-standing biomechanical stress on the anterior arches of the feet.
Treatment Plan
Adjustments. Specific adjustments were provided to the lumbopelvic region. Both feet also received adjustments for collapsed anterior transverse metatarsal arches.
Support. He was fitted with custom-made, flexible stabilizing orthotics designed to provide support for the anterior transverse arches, under the metatarsal heads. The orthotics were made with viscoelastic, shock-absorbing materials, in order to support all three arches and limit gravitational stress when standing and walking.
Rehabilitation. This active patient was told to continue his personal exercise program. He was instructed in a series of foot exercises (marble pick-up and towel-scrunching) to improve the coordination and strength of his anterior foot intrinsic muscles.
Response to Care
He responded well to the adjustments and exercises, and reported a rapid decrease in foot symptoms. Initially, he didn’t notice any change when wearing his orthotics, but within three weeks he no longer had any of the previous irritation in his feet. After eight weeks, his calluses were softer, and he had no more progression. He was released to a self-directed maintenance program after a total of ten treatment sessions over two months. When re-evaluated at a six-month check-up visit, he reported that his calluses had decreased significantly, and were no longer causing problems.
Discussion
This high-powered, active executive experienced unusual levels of repetitive biomechanical stress to his anterior arches, which resulted in callus formation. He responded well to conservative chiropractic care and custom-made orthotics. The best treatment for these types of problems is a conservative approach, with a combination of chiropractic adjustments, flexible orthotic support, corrective exercises, and education.
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program and lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System. He can be reached by e-mail at [email protected].